Peripelvic urinoma associated with benign pro static hypertrophy
3
PERIPELVIC URINO’MA ASSOCIATED WITH BENIGN PROSTATIC HYPERTROPHY BALBIR SINGH, M.D. HONG KIM, M.D. SANDOR H. WAX, M.D. From the Department of Urology, Brookdale Hospital Medical Center, Brooklyn, New York ABSTRACT -A case report of a large peripelvic urinoma which disappeared after decompression of a distended obstructed bladder is presented. The etiology of this rare complication of bladder outlet obstruction is reviewed and discussed. The majority of cases of spontaneous peripelvic extravasation associated with ureteral obstruc- tion are due to an obstructing calculus and rarely to a ureteral tumor.i,2 We report herein a case of peripelvic extravasation due to bladder neck obstruction related to benign prostatic hypertrophy. Case Report A sixty-eight-year-old Caucasian man with the chief complaint of severe pain in the upper left abdominal quadrant for two weeks was admitted to Brookdale Hospital Medical Center. He gave a history of frequency, nocturia, and dysuria for one year. Physical examination revealed a 15- cm., tender, easily palpable mass in the upper left abdominal quadrant. There was another midline mass in the suprapubic region extend- ing 3 fingerbreadths above the pubic symphysis which was thought to be the bladder. A reduci- ble asymptomatic right inguinal hernia was also present. Rectal examination revealed a nonten- der, symmetrical prostate weighing approxi- mately 50 Gm. Laboratory studies revealed: hemoglobin 10 Cm. per 100 ml., hematocrit 32.4, blood urea nitrogen 34 mg. and serum creatinine 2.2 mg. per 100 ml., and urine cul- ture showed no growth. An intravenous pyelogram with administra- tion of 50 cc: of sodium diatrizoate (Hypaque) revealed bilateral hydroureteronephrosis grade III to IV. An associated finding was massive ex- travasation of dye medial to the left kidney which appeared to enter a urinoma (Fig. 1A). A large distended bladder which did not empty was also present (Fig. 1B). An indwelling Foley catheter was placed. Within twenty-four hours the upper left abdominal quadrant pain and tenderness subsided, and the mass appeared to be smaller in size. A repeat intravenous pyelo- gram on the eighth hospital day revealed marked improvement in the hydronephrosis and disappearance of the urinoma (Fig. 1C). Sub- sequently, the patient underwent a transure- thral prostatectomy. Pathologic report revealed benign prostatic hypertrophy. He had an uneventful postoperative course. Two months later a repeat intravenous pyelo- gram revealed more improvement of the hy- dronephrosis (Fig. 1D). Comment Spontaneous peripelvic extravasation is caused by rupture of the fornix of a calyx which leads to backflow of urine into the renal sinus. From the sinus the extravasation could enter the venous system leading to pyelovenous backflow, or it may reach the retroperitoneal space by traveling around the pelvis.3 This was also shown in cadaver kidneys.4 The pathway of this extravasation has been graphically demon- strated by fluoroscopy and spot films.5 Olsson’ described 100 cases of extravasation in patients with elevated intrapelvic pressure caused by 600 UROLOGY / DECEMBER 1979 / VOLUME XIV, NUMBER 6
-
Upload
balbir-singh -
Category
Documents
-
view
212 -
download
0
Transcript of Peripelvic urinoma associated with benign pro static hypertrophy
PERIPELVIC URINO’MA ASSOCIATED WITH
BENIGN PROSTATIC HYPERTROPHY
BALBIR SINGH, M.D.
HONG KIM, M.D.
SANDOR H. WAX, M.D.
From the Department of Urology, Brookdale Hospital Medical Center, Brooklyn, New York
ABSTRACT -A case report of a large peripelvic urinoma which disappeared after decompression of a distended obstructed bladder is presented. The etiology of this rare complication of bladder outlet obstruction is reviewed and discussed.
The majority of cases of spontaneous peripelvic extravasation associated with ureteral obstruc- tion are due to an obstructing calculus and rarely to a ureteral tumor.i,2 We report herein a case of peripelvic extravasation due to bladder neck obstruction related to benign prostatic hypertrophy.
Case Report
A sixty-eight-year-old Caucasian man with the chief complaint of severe pain in the upper left abdominal quadrant for two weeks was admitted to Brookdale Hospital Medical Center. He gave a history of frequency, nocturia, and dysuria for one year. Physical examination revealed a 15- cm., tender, easily palpable mass in the upper left abdominal quadrant. There was another midline mass in the suprapubic region extend- ing 3 fingerbreadths above the pubic symphysis which was thought to be the bladder. A reduci- ble asymptomatic right inguinal hernia was also present. Rectal examination revealed a nonten- der, symmetrical prostate weighing approxi- mately 50 Gm. Laboratory studies revealed: hemoglobin 10 Cm. per 100 ml., hematocrit 32.4, blood urea nitrogen 34 mg. and serum creatinine 2.2 mg. per 100 ml., and urine cul- ture showed no growth.
An intravenous pyelogram with administra- tion of 50 cc: of sodium diatrizoate (Hypaque) revealed bilateral hydroureteronephrosis grade III to IV. An associated finding was massive ex-
travasation of dye medial to the left kidney which appeared to enter a urinoma (Fig. 1A). A large distended bladder which did not empty was also present (Fig. 1B). An indwelling Foley catheter was placed. Within twenty-four hours the upper left abdominal quadrant pain and tenderness subsided, and the mass appeared to be smaller in size. A repeat intravenous pyelo- gram on the eighth hospital day revealed marked improvement in the hydronephrosis and disappearance of the urinoma (Fig. 1C). Sub- sequently, the patient underwent a transure- thral prostatectomy. Pathologic report revealed benign prostatic hypertrophy.
He had an uneventful postoperative course. Two months later a repeat intravenous pyelo- gram revealed more improvement of the hy- dronephrosis (Fig. 1D).
Comment
Spontaneous peripelvic extravasation is caused by rupture of the fornix of a calyx which leads to backflow of urine into the renal sinus. From the sinus the extravasation could enter the venous system leading to pyelovenous backflow, or it may reach the retroperitoneal space by traveling around the pelvis.3 This was also shown in cadaver kidneys.4 The pathway of this extravasation has been graphically demon- strated by fluoroscopy and spot films.5 Olsson’ described 100 cases of extravasation in patients with elevated intrapelvic pressure caused by
600 UROLOGY / DECEMBER 1979 / VOLUME XIV, NUMBER 6
FIGURE 1. Intravenous pyelograms: (A) extravasation of dye medial to le$ kidney and wall of urinoma; (B) extrauasation of dye and distended bladder in postvoid film; (C) aft er eight days of indwelling Foley catheter drainage of bladder urinoma disappeared and hydronephrosis improved; (D) more improvement in hy- dronephrosis two months post-transurethral prostatectomy.
UROLOGY / DECEMBER1979 / VOLUMEXIV, NUMBER6 601
either intrinsic ureteric obstruction or by exter- nal obstruction due to compression applied dur- ing an intravenous pyelogram.
In our case the extravasation was a chronic process. It probably had been present for at least two weeks corresponding to the presence of pain in the left quadrant. The extravasated urine most likely initiated an inflammatory re- sponse in the surrounding tissue which in turn led to formation of collagen and fibrous tissue which walled off the collected urine. A urinoma is usually completely resolved when the obstruction is removed, and in our case this was rapidly accomplished by decompression of the bladder. Urinomas, at times, do not resolve and may lead to urinary granuloma,’ perinephric abscess,* or retroperitoneal fibrosis.g
Most cases of spontaneous extravasation re- ported in the literature are caused by ureteral obstruction due to a calculus. A few cases of ureteral obstruction were reported due to ure- teral tumor. One interesting case of extravasa- tion due to bladder outlet obstruction after infu- sion pyelogram was reported by Bernardino and McClennan.‘O A case of posterior urethral valve with urinoma in a newborn was reported by Friedberg and Scully. l1
In our case prostatic obstruction led to bilat- eral ureterohydronephrosis. This in turn led to
peripelvic extravasation caused by increased pressure and eventually led to the formation of a urinoma. Bladder decompression resulted in complete regression of extravasation and the urinoma.
Brooklyn, New York 11212 (DR. WAX)
References
1. Ginsberg SA: Spontaneous urinary extravasation in associa- tion with renal colic, J. Ural. 94: 192 (1965).
2. Twersky J, Twerksy N, Phillips G, and Coppersmith H: Perinelvic extravasation, urinoma formation and tumor obstruction of ureter, ibid. 116: 305 (1976).
3. Stawr K: Calvco-renal backflow. Br. I. Ural. 39: 753 (1967). 4. Hiiman F, jr: Peripelvic extravasation during intravenous
urography, evidence for an additional route for backflow atter ure- teral obstruction, J. Ural. 85: 385 (1961).
5. Schwartz A, Caine M, Hermann G, and Bitterman W: Spon- taneous renal extravasation during intravenous urography, Am. J. Roentgenol. 98: 27 (1966).
6. Olsson 0: Studies on backflow in excretion urography, Acta Radial. Suppl. 70, 1948.
7. Pawlowski JM: Peripelvic urine granuloma, Am. J. Clin. Pa&l. 34: 64 (1966).
8. Harrow BR: Spontaneous extravasation associated with renal colic causing a perinephric abscess, Am. J. Roentgenol. 98: 47 (1966).
9. Mitchinson MJ, and Bird DR: Urinary leakage and ret- roperitoneal fibrosis, J. Ural. 105: 56 (1971).
10. Bernardino ME, and McClennan BL: High-dose urog- raphy: incidence and relationship to spontaneous peripelvic ex- travasation, Am. J. Roentgenol. 127: 373 (1976).
11. Friedberg RM, and Scully RE: Cystic mass of recent origin in elderly woman, N. Engl. J. Med. 297: 1454 (1977).
602 UROLOGY / DECEMBER 1979 / VOLUME XIV, NUMBER 6
